Provider Demographics
NPI:1013224682
Name:BLOSSOM HEALTHCARE, INC.
Entity Type:Organization
Organization Name:BLOSSOM HEALTHCARE, INC.
Other - Org Name:BLOSSOM HEALTHCARE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:INNOCENT
Authorized Official - Middle Name:I
Authorized Official - Last Name:OBETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-822-0061
Mailing Address - Street 1:9894 BISSONNET STREET
Mailing Address - Street 2:SUITE 422
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036
Mailing Address - Country:US
Mailing Address - Phone:281-822-0061
Mailing Address - Fax:281-822-0060
Practice Address - Street 1:9894 BISSONNET STREET
Practice Address - Street 2:SUITE 422
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036
Practice Address - Country:US
Practice Address - Phone:281-822-0061
Practice Address - Fax:281-822-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-02
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000000000251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX299945001Medicaid